Division of Vascular Surgery, Department of Surgery, University of North Carolina, Chapel Hill, NC.
Division of Vascular Surgery, Department of Surgery, University of North Carolina, Chapel Hill, NC.
J Vasc Surg. 2024 Aug;80(2):302-310. doi: 10.1016/j.jvs.2024.04.017. Epub 2024 Apr 10.
The aim of this study was to evaluate the 5-year outcomes of fenestrated/branched endovascular aortic repair (F/BEVAR) for the treatment of complex aortic aneurysms stratified by the aneurysm extent.
Patients with the diagnosis of complex aortic aneurysm, who underwent F/BEVAR at a single center were included in this study and retrospectively analyzed. The cohort was divided according to the aneurysm extent, comparing group 1 (types I-III thoracoabdominal aneurysms [TAAAs]), group 2 (type IV TAAAs), and group 3 (juxtarenal [JRAAs], pararenal [PRAAs], or paravisceral [PVAAs] aortic aneurysms). The primary endpoints were 30-day and 5-year survival. The secondary endpoints were technical success, occurrence of spinal cord ischemia, primary patency of the visceral arteries, freedom from target vessel instability, and secondary interventions.
Of 436 patients who underwent F/BEVAR between July 2012 and May 2023, 131 presented with types I to III TAAAs, 69 with type IV TAAAs, and 236 with JRAAs, PRAAs, or PVAAs. All cases were treated under a physician-sponsored investigational device exemption protocol with a patient-specific company-manufactured or off-the-shelf device. Group 1 had significantly younger patients than group 2 or 3 respectively (69.6 ± 8.7 vs 72.4 ± 7.1 vs 73.2 ± 7.3 years; P < .001) and had a higher percentage of females (50.4% vs 21.7% vs 17.8%; P < .001). Prior history of aortic dissection was significantly more common among patients in group 1 (26% vs 1.4% vs 0.9%; P < .001), and mean aneurysm diameter was larger in group 1 (64.5 vs 60.7 vs 63.2 mm; P = .033). Comorbidities were similar between groups, except for coronary artery disease (P < .001) and tobacco use (P = .003), which were less prevalent in group 1. Technical success was similar in the three groups (98.5% vs 98.6% vs 98.7%; P > .99). The 30-day mortality was 4.5%, 1.4%, and 0.4%, in groups 1, 2, and 3, respectively, and was significantly higher in group 1 when compared with group 3 (P = .01). The incidence of spinal cord ischemia was significantly higher in group 1 compared with group 3 (5.3% vs 4.3% vs 0.4%; P = .004). The 5-year survival was significantly higher in group 3 when compared with group 1 (P = .01). Freedom from secondary intervention was significantly higher in group 3 when compared with group 1 (P = .003). At 5 years, there was no significant difference in freedom from target vessel instability between groups or primary patency in the 1652 target vessels examined.
Larger aneurysm extent was associated with lower 5-year survival, higher 30-day mortality, incidence of secondary interventions, and spinal cord ischemia. The prevalence of secondary interventions in all groups makes meticulous follow-up paramount in patients with complex aortic aneurysm treated with F/BEVAR.
本研究旨在评估基于动脉瘤范围对复杂主动脉瘤行腔内分支/开窗治疗（F/BEVAR）的 5 年结果。
本研究回顾性分析了在单一中心接受 F/BEVAR 治疗的复杂主动脉瘤患者。根据动脉瘤范围，将患者分为三组：第 1 组（I-III 型胸腹主动脉瘤[TAAAs]）、第 2 组（IV 型 TAAAs）和第 3 组（肾下主动脉瘤、肾旁主动脉瘤或腹膜后主动脉瘤）。主要终点是 30 天和 5 年生存率。次要终点是技术成功率、脊髓缺血、内脏动脉通畅性、靶血管稳定性和二次干预。
在 2012 年 7 月至 2023 年 5 月期间接受 F/BEVAR 的 436 例患者中，131 例患者为 I-III 型 TAAAs，69 例为 IV 型 TAAAs，236 例为肾下、肾旁或腹膜后主动脉瘤。所有患者均在医生赞助的研究性器械豁免方案下接受治疗，使用特定于患者的公司制造或定制设备。第 1 组患者明显比第 2 组或第 3 组更年轻（69.6±8.7 岁比 72.4±7.1 岁比 73.2±7.3 岁；P<0.001），女性比例更高（50.4%比 21.7%比 17.8%；P<0.001）。第 1 组患者中既往有主动脉夹层病史的比例明显更高（26%比 1.4%比 0.9%；P<0.001），且第 1 组的平均动脉瘤直径较大（64.5 毫米比 60.7 毫米比 63.2 毫米；P=0.033）。各组之间的合并症相似，但冠状动脉疾病（P<0.001）和吸烟史（P=0.003）除外，第 1 组中这两种情况的比例较低。三组之间的技术成功率相似（98.5%比 98.6%比 98.7%；P>0.99）。第 1 组、第 2 组和第 3 组的 30 天死亡率分别为 4.5%、1.4%和 0.4%，第 1 组明显高于第 3 组（P=0.01）。第 1 组脊髓缺血的发生率明显高于第 3 组（5.3%比 4.3%比 0.4%；P=0.004）。第 3 组的 5 年生存率明显高于第 1 组（P=0.01）。与第 1 组相比，第 3 组的二次干预率显著较低（P=0.003）。5 年时，各组之间靶血管稳定性的差异无统计学意义，1652 个目标血管的通畅性无显著差异。
更大的动脉瘤范围与较低的 5 年生存率、较高的 30 天死亡率、较高的二次干预发生率和脊髓缺血发生率相关。所有组的二次干预发生率都很高，这使得对接受 F/BEVAR 治疗的复杂主动脉瘤患者进行精心的随访至关重要。
